Withdrawal Request Form - Great-West Life
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1
2Regular Mail to:
Overnight Mail to:
Great-West Life & Annuity Insurance
Great-West Life & Annuity Insurance
Company
Company
Attn: RROC
Attn: RROC
PO Box 173920
8515 E Orchard Road 8T2
Denver, CO 80217-3920
Greenwood Village, CO 80111
Phone: (800) 838-0650 option 2
Phone: (800) 838-0650 option 2
Fax: (866) 442-3887
Fax: (866) 442-3887
WITHDRAWAL REQUEST FORM
Owner Name ______________________________________________
Group_____________________________________________
Owner
Annuity
Social Security No.___________________________ Ext ___________
Number ____________________________________________
Owner Address:
Street ____________________________________________________
City___________________ State________ Zip ____________
Owner Phone Numbers:
Daytime __________________________________________________
Evening ___________________________________________
1.
PERIODIC WITHDRAWAL REQUEST
(Not available on Claims) (Minimum withdrawal amount for each payment is $100)
Complete Sections 1, 4, 5 & 6 to request periodic withdrawals under your annuity.
Allow 10 business days for initial set-up.
Payments to be made every
1 month
3 months
6 months
12 months
Payment Start Date: __________________
(Mon/Day/Year)
If the payment start date has passed, the first payment will be processed the date we receive the request in good order. Future
payments will be made on the next scheduled payment date based on the requested start date.
Please check one of the following:
Period Certain (Payments continue for a specified period of time.) for __________ months
Payment Certain (Payments of a specific dollar amount.) $____________________
You may have your distribution withdrawn either on a pro-rata basis among your active sub-accounts or by specific percentages from
designated sub-accounts. Percentages must be whole numbers and must total 100%.
A.
Pro-rata liquidation OR B.
Liquidate by sub account as shown below
2.
PARTIAL WITHDRAWAL REQUEST (Minimum withdrawal amount is $500)
Complete Sections 2, 4, 5 & 6 to request a partial withdrawal under your annuity.
I, the undersigned, hereby elect to make a partial withdrawal under the Partial Withdrawal Benefit provision of the above ref erenced
Annuity in the amount of:
$______________________ (OR __________________% of Account Value).
PLEASE NOTE: Whenever a partial withdrawal is elected, the Annuity Account Value may not drop below $2,000. Therefore, the
maximum amount available for a partial withdrawal is the annuity surrender value, as described in the annuity, less $2,000.
You may have your distribution withdrawn either on a pro-rata basis among your active sub-accounts or by specific percentages or
dollar amounts from designated sub-accounts. Percentages must be whole numbers and must total 100%.
A.
Pro-rata liquidation OR B.
Liquidate by sub account as shown below.
Please check
% or
dollar amount.
3.
FULL SURRENDER REQUEST
Complete Sections 3, 4, 5 & 6 to request a full surrender
Please Check One:
I have enclosed the original annuity.
I have not enclosed the original annuity, as it has been lost or misplaced.
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